Liver atrophy and portal stenosis in two cases of sclerosing cholangitis associated with autoimmune pancreatitis

Sclerosing cholangitis with autoimmune pancreatitis (SC with AIP) takes a better clinical course than primary sclerosing cholangitis due to the effectiveness of steroid therapy. However, the morphological and functional changes in SC with AIP during long-term observation have not yet been reported. We encountered two cases of SC with AIP that resulted in liver atrophy and portal obstruction during long-term observation. One case was followed up without steroid therapy. The other case was treated with endoscopic biliary drainage initially. These cases may provide further information regarding steroid therapy for SC with AIP.

[Primary sclerosing cholangitis of small ducts, associated with eosinophilic gastroenteritis. Case report and literature review.]

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown etiology, probably immune-mediated. PSC is frequently associated with Inflammatory Bowel Disease, usually Ulcerative Colitis and less commonly with Crohn's disease. The small-duct PSC variant occurs in 5%of patients. Eosinophilic gastroenteritis (EG) is another chronic inflammatory disease, characterized by eosinophilic infiltration limited to the digestive tract, and probably of immunoallergic origin. EG is frequently observed in children but it's less commonly seen in adults. EG can affect any segment of the gastrointestinal tract, and recently it has been described an increase in the incidence of the esophagic variant, termed eosinophilic esophagitis.Ileocolonic involvement in EG is rare and clinical manifestations depend of the intestinal layer affected. Patients with mucosal infiltration complain of abdominal pain, fecal occult blood loss and/or protein-losing enteropaty, while signs and symptoms of obstruction are common in those with muscular EG, finally involvement of the serosal layer occurs in 10% and typically presents as eosinophil-rich ascitis. Response to steroids usually is excellent. There is a previous publication in the literature documenting the association of PSC and EG. Here we describe the first case of small-duct PSC associated to EG with ileocolonic involvement.

[A case of sclerosing cholangitis showing response to prednisolone]

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by progressive fibrosis and destruction of intra- and extrahepatic bile ducts resulting in hepatic failure and death. Only the liver transplantation is the possible treatment for patients to survive. There has been a few reports that steroid is an effective treatment in autoimmune variant sclerosing cholangitis, which is thought to be a familial diseases with different etiology, and steroid responsive biliary strictures be named as immunoglobulin G4 (IgG4)-associated cholangitis (IAC). There is no reliable data regarding effective steroid treatment in autoimmune variant sclerosing cholangitis in Korea. We report a case of 32-year-old male with sclerosing cholangitis, who was diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) and liver biopsy, showing favorable response to prednisolone therapy.

Helicobacter pylori may play a contributory role in the pathogenesis of primary sclerosing cholangitis

Helicobacter pylori (H. pylori) DNA has been identified in human livers and has been implicated in chronic liver disease and liver cancer. To better understand the role of H pylori in primary sclerosing cholangitis (PSC), 25 patients with end-stage PSC and 31 controls were studied. Genomic DNA was extracted from microdissected hilar hepatic ducts of liver explants and was amplified for H pylori DNA. Serum was tested for H pylori antibodies. Helicobacter DNA was detected in 9 of the 56 (16%) patients by 16SrRNA PCR (an additional case [for a total of 18%] was antibody positive). Seven of the 9 cases identified by polymerase chain reaction were positive for the CagA gene, confirming they were H pylori. Seven of the 25 (28%) patients with PSC and 3 of the 31 (9.7%) controls were positive for Helicobacter (P=.087). H pylori DNA was detected in microdissected hilar biliary epithelium in more PSC patients than controls, supporting the hypothesis that bile reflux from the duodenum into the biliary tract might carry H pylori organisms into the proximal biliary system, possibly contributing to PSC development and/or progression in some patients.

Immunoglobin G4-hepatopathy: association of immunoglobin G4-bearing plasma cells in liver with autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is characterized by high serum immunoglobin (Ig) G4 concentrations, lymphoplasmacytic inflammation, and a favorable response to corticosteroid treatment. Since liver dysfunction is frequently seen in AIP patients, we investigated hepatic histopathology and its clinical significance in patients with AIP. We examined the clinical features, histology, and immunoglobin G (IgG)4-bearing plasma cell infiltration of liver biopsies from 17 patients with AIP and 63 patients with either autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, or chronic viral hepatitis and histological changes in the 7 of 17 livers before and after glucocorticoid therapy. The liver histology of AIP was classified into 5 patterns: evident portal inflammation with or without interface hepatitis (6 cases), large bile-duct obstructive features (8 cases), portal sclerosis (8 cases), lobular hepatitis (5 cases), and canalicular cholestasis (4 cases); some of the histological features coexisted in the same liver. The number of IgG4-bearing plasma cells was significantly higher in AIP patients than controls (P < 0.01), and was significantly correlated with serum IgG4 concentration (P = 0.0014, r = 0.709). Glucocorticoid therapy reduced IgG4-bearing plasma cell infiltration in the liver (P = 0.031) and ameliorated other histological findings. In conclusion, virtually all AIP liver biopsies showed evidence of various pathological changes and infiltration of IgG4-bearing plasma cells. These features were ameliorated by steroid therapy, suggesting that the liver is concurrently affected in AIP, and that liver biopsies can provide significant information in the clinical evaluation and diagnosis of AIP.

Clinicopathological differentiation between sclerosing cholangitis with autoimmune pancreatitis and primary sclerosing cholangitis

BACKGROUND

The present study was undertaken to identify the clinicopathological differences between sclerosing cholangitis with autoimmune pancreatitis (SC-AIP) and primary sclerosing cholangitis (PSC).

METHODS

We retrospectively compared the clinical, cholangiographic, and liver biopsy findings between 24 cases of PSC and 24 cases of SC-AIP.

RESULTS

Patient age at the time of diagnosis was significantly lower in the PSC group than in the SC-AIP group. The peripheral blood eosinophil count was significantly higher in the PSC group than in the SC-AIP group, but the serum IgG4 level was significantly higher in the SC-AIP group. Cholangiography revealed band-like strictures, beaded appearance, and pruned-tree appearance significantly more frequently in PSC, whereas segmental strictures and strictures of the distal third of the common bile duct were significantly more common in SC-AIP. Liver biopsy revealed fibrous obliterative cholangitis only in the PSC specimens. No advanced fibrous change corresponding to Ludwig's stages 3 and 4 was observed in any of the SC-AIP specimens. IgG4-positive plasma cell infiltration of the liver was significantly more severe in SC-AIP than in PSC. Subsequent cholangiography showed no improvement in any of the PSC cases, but all SC-AIP patients responded to steroid therapy, and improvement in the strictures was observed cholangio-graphically.

CONCLUSIONS

Based on the differences between the patients' ages and blood chemistry, cholangiographic, and liver biopsy findings, SC-AIP should be differentiated from PSC.

Prevalence and Risk Factors for Gallbladder Neoplasia in Patients With Primary Sclerosing Cholangitis: Evidence for a Metaplasia-Dysplasia-Carcinoma Sequence

Primary sclerosing cholangitis (PSC) carries an increased risk (10% to 20%) of hepatobiliary malignancy, especially cholangiocarcinoma (CC). Dysplasia, adenomas, and carcinomas of the gallbladder have been described in PSC but are less common than bile duct carcinomas. However, the prevalence and risk factors for gallbladder neoplasia among patients with PSC undergoing orthotopic liver transplantation (OLT) have not been well studied. We evaluated 72 gallbladders from 100 consecutive liver explants for PSC, including 66 cholecystectomies performed at the time of OLT and 6 performed before OLT. All specimens were totally embedded for histologic examination. We evaluated the following histologic features: presence of diffuse lymphoplasmacytic chronic cholecystitis, pyloric metaplasia, intestinal metaplasia, dysplasia (low-grade or high-grade), and adenocarcinoma. Gallbladder dysplasia and adenocarcinoma were correlated with several clinicopathologic parameters using Fisher exact test and t test, including: (1) sex, (2) age, (3) PSC duration, (4) inflammatory bowel disease (IBD) at time of OLT, and (5) concomitant bile duct dysplasia or carcinoma. Lymphoplasmacytic chronic cholecystitis was present in 35 (49%), pyloric metaplasia in 69 (96%), intestinal metaplasia in 36 (50%), dysplasia in 27 (37%; low-grade in 12 and high-grade in 15), and adenocarcinoma in 10 (14%; 2 with lamina propria invasion and 8 with invasion into muscularis or adventitia). Gallbladder carcinoma was associated with intrahepatic bile duct dysplasia (P=0.001), CC (P=0.023), and IBD (P=0.03). Gallbladder dysplasia was associated with hilar/intrahepatic bile duct dysplasia (P=0.0006), CC (P=0.028), IBD (P=0.0014), and older age at OLT (P=0.007). Neither gallbladder carcinoma nor dysplasia had a significant association with sex or PSC duration. These results indicate that complete histologic evaluation of gallbladders in patients undergoing transplantation for PSC yields high frequencies of inflammatory, metaplastic, and neoplastic changes. The strong correlation between gallbladder dysplasia/adenocarcinoma and bile duct dysplasia/CC supports the concept of a neoplastic "field effect" along the intrahepatic and extrahepatic biliary tract in PSC.

Biliary intraepithelial neoplasia: an international interobserver agreement study and proposal for diagnostic criteria

Cholangiocarcinoma of the intrahepatic and extrahepatic bile ducts develops through a multistep histopathologic sequence. Premalignant or non-invasive neoplastic lesions of bile ducts have been historically called biliary dysplasia or atypical biliary epithelium. To this date, no standard terminology or classification system has been offered for these lesions. In 2005, a conceptual framework and diagnostic criteria for biliary intraepithelial neoplasia (BilIN) were proposed using the livers of patients with hepatolithiasis. We report herein an international interobserver agreement study on the diagnosis of biliary non-invasive neoplastic lesions with the goal to obtain a consensus on the terminology and grading. Seventeen pathologists from the United States, Europe and Asia participated in this study. They shared a digital file containing histological pictures of 30 foci of non-invasive neoplastic lesions selected from the biliary system of patients suffering from primary sclerosing cholangitis, choledochal cyst or hepatolithiasis. In the criteria, we proposed in 2005, BilIN was classified into three categories based on the degree of atypia: BilIN-1, BilIN-2 and BilIN-3. In this study, consensus was reached for the terminology of BilIN and the three-grade classification system. Interobserver agreement on the diagnosis was moderate (kappa-value=0.45). On the basis of the suggestions and opinions obtained from the 17 participants, the original criteria for BilIN were revised. We now propose a new consensus classification of BilIN that may assist in allowing a more uniform terminology for the diagnosis of biliary non-invasive neoplastic lesions. This classification should help to advance clinical and research applications.

Biliary epithelial cell antibodies link adaptive and innate immune responses in primary sclerosing cholangitis

BACKGROUND & AIMS

Primary sclerosing cholangitis (PSC) is an autoimmune liver disease with destruction of hepatic bile ducts. A high frequency of biliary epithelial cell antibodies (BEC-Ab) is present in PSC. Here, we studied the mechanisms and signaling pathways used by these Ab in causing BEC dysfunction.

METHODS

Immunoassays were performed using freshly isolated BECs to study the signaling capacity of purified immunoglobulin (Ig) G and F(ab)'(2) fractions from 33 patients with PSC with anti-BEC-Ab.

RESULTS

We provide evidence that stimulation of BECs with PSC IgG, but not control IgG, induced expression of Toll-like receptor (TLR) 4 and TLR9 and specific phosphorylation of extracellular signal-regulated kinase (ERK) 1/2 as well as the transcription factors ELK-1 and nuclear factor kappaB. A specific inhibitor of ERK1/2 abrogated phosphorylation of ELK-1 and protein expression of TLR4 but not TLR9 on BECs. TLR-expressing BECs, when further stimulated with lipopolysaccharide and CpG DNA, produced high levels of interleukin-1beta, interleukin-8, interferon gamma, tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, and transforming growth factor beta. Bile ducts stained positively for TLR4 and TLR9 in 58% of liver specimens taken from patients with PSC with BEC-Ab, as compared with 14% in those without BEC-Ab and also less frequently in diseased control livers.

CONCLUSIONS

Our data show that binding of PSC BEC-Ab initiates ERK1/2 signaling and up-regulation of TLR, which upon ligation induces BECs to produce cytokines/chemokines, leading to the possible recruitment of inflammatory cells. Thus, in PSC, BECs are not only targets of the immune attack but may also be active participants and mediators of their own destruction. BEC-Ab may be critical regulators of cholangitis in PSC.

Autoimmune liver disease: overlap and outliers

The three main categories of autoimmune liver disease are autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC); all are well-defined entities with diagnosis based upon a constellation of clinical, serologic, and liver pathology findings. Although these diseases are considered autoimmune in nature, the etiology and possible environmental triggers of each remain obscure. The characteristic morphologic patterns of injury are a chronic hepatitis pattern of injury with prominent plasma cells in AIH, destruction of small intrahepatic bile ducts and canals of Hering in PBC, and periductal fibrosis and inflammation involving larger bile ducts with variable small duct damage in PSC. Serological findings include the presence of antimitochondrial antibodies in PBC, antinuclear, anti-smooth muscle, and anti-LKM antibodies in AIH, and pANCA in PSC. Although most cases of autoimmune liver disease fit readily into one of these three categories, overlap syndromes (primarily of AIH with PBC or PSC) may comprise up to 10% of cases, and variant syndromes such as antimitochondrial antibody-negative PBC also occur. Sequential syndromes with transition from one form of autoimmune liver disease to another are rare.

An autopsy case showing massive fibrinoid necrosis of the portal tracts of the liver with cholangiographic findings similar to those of primary sclerosing cholangitis

An 81-year-old Japanese man with jaundice was strongly suspected clinically of having primary sclerosing cholangitis based on clinical examinations and later died of hepatic failure. The entire course of the disease lasted about 10 mo. The autopsy revealed extensive fibrinoid necrosis in the liver, kidney, spleen, pancreas, lung, lymph nodes, and pleura. Particularly extensive fibrinoid necrosis in the portal tracts of the liver induced severe stenoses of the intrahepatic bile ducts, resulting in cholestasis in association with prominent liver injury. There were no findings indicating primary sclerosing cholangitis. The hepatic lesions in this case did not coincide with any known disease including collagen diseases. To clarify the cause of irregular stenoses of the intrahepatic biliary trees on cholangiographic findings, we postulate that some form of immunological derangement might be involved in pathogenesis of fibrinoid necrosis. However, the true etiology remains unknown.

Dynamic FDG-PET is useful for detection of cholangiocarcinoma in patients with PSC listed for liver transplantation

Five to 15% of patients with primary sclerosing cholangitis (PSC) develop cholangiocarcinoma (CC) with a median survival of 5 to 7 months, an outcome not significantly improved by liver transplantation. However, if CC is found incidentally during the procedure or in the explanted liver, 5-year survival rates of 35% are reported. A noninvasive method to detect CC small enough to allow for intended curative surgery is needed. Unfortunately, computed tomography (CT) and ultrasonography (US) have poor sensitivity for detection of CC in PSC; however, positron emission tomography (PET) using 2-[18F]fluoro-2-deoxy-D-glucose (FDG) differentiates well between CC and nonmalignant tissue. We examined whether PET findings are valid using a blinded study design comparing pretransplantation FDG-PET results with histology of explanted livers. Dynamic FDG-PET was performed in 24 consecutive patients with PSC within 2 weeks after listing for liver transplantation and with no evidence of malignancy on CT, magnetic resonance imaging, or ultrasonography. The PET Center staff was blinded to clinical findings, and surgeons and pathologists were blinded to the PET results. Three patients had CC that was correctly identified by PET. PET was negative in 1 patient with high-grade hilar duct dysplasia. In 20 patients without malignancies, PET was false positive in 1 patient with epitheloid granulomas in the liver. In conclusion, dynamic FDG-PET appears superior to conventional imaging techniques for both detection and exclusion of CC in advanced PSC. FDG-PET may be useful for screening for CC in the pretransplant evaluation of patients with PSC.

Changes of the hepatic proteome in murine models for toxically induced fibrogenesis and sclerosing cholangitis

We investigated the changes in the hepatic proteome in murine models for toxic-induced fibrogenesis and sclerosing cholangitis. A comprehensive comparison of protein changes observed is made and the mechanistical basis of the expression changes is discussed. Hepatic fibrosis was induced by repetitive intraperitoneal CCl4 treatment of BALB/c mice or developed spontaneously in BALB/c-ATP-binding cassette, subfamily B, member 4 (Abcb4) knock out mice. Fibrosis was verified by a morphometric score and assessment of hydroxyproline content of liver tissue, respectively. The innovative difference in-gel electrophoresis (DIGE) technique was used to analyse protein expression levels of the mouse proteome. Results were confirmed by Western blotting and real-time RT-PCR. In CCl4-induced fibrosis 20 out of 40 and in BALB/c-Abcb4(-/-) mice 8 out of 28 differentially expressed proteins were identified utilizing DIGE. Only two proteins, selenium-binding protein (Sbp2) and carbonic anhydrase 3, have been unidirectionally expressed (i.e. down-regulated) in both models. Relevant differences in the pathogenesis of toxically induced liver fibrosis and sclerosing cholangitis exist. The only novel protein with regard to liver fibrosis depicting a unidirectional expression pattern in both animal models was Sbp2. An explicit protein function could not be clarified yet.

Recurrent primary sclerosing cholangitis: Clinical diagnosis and long-term management issues

1. Primary sclerosing cholangitis (PSC) in the nontransplant setting is a chronic, progressive liver disease characterized by diffuse stricturing of the biliary tree, cholestatic liver enzymes, and a compatible liver biopsy. 2. Cholangiography reveals irregularity of the bile duct wall, strictures, beading, and diverticula. 3. The typical biopsy reveals inflammation and fibrosis of the interlobular and septal bile ducts, often with obliteration or biliary-type cirrhosis. 4. The precise pathogenetic mechanism remains elusive but is assumed to be an autoimmune phenomenon. 5. For patients with end-stage complications of PSC, such as liver failure, recurrent bacterial cholangitis, and intractable pruritus, liver transplantation is an acceptable treatment option.

Sclerosing cholangitis: a focus on secondary causes

Secondary sclerosing cholangitis (SSC) is a disease that is morphologically similar to primary sclerosing cholangitis (PSC) but that originates from a known pathological process. Its clinical and cholangiographic features may mimic PSC, yet its natural history may be more favorable if recognition is prompt and appropriate therapy is introduced. Thus, the diagnosis of PSC requires the exclusion of secondary causes of sclerosing cholangitis and recognition of associated conditions that may potentially imitate its classic cholangiographic features. Well-described causes of SSC include intraductal stone disease, surgical or blunt abdominal trauma, intra-arterial chemotherapy, and recurrent pancreatitis. However, a wide variety of other associations have been reported recently, including autoimmune pancreatitis, portal biliopathy, eosinophillic and/or mast cell cholangitis, hepatic inflammatory pseudotumor, recurrent pyogenic cholangitis, primary immune deficiency, and AIDS-related cholangiopathy. This article offers a comprehensive review of SSC.

Distinguishing between recurrent primary sclerosing cholangitis and chronic rejection

1. Recurrent primary sclerosing cholangitis (PSC) is extremely difficult, if not impossible, to distinguish from other causes of biliary strictures or sclerosing cholangitis in allografts using needle biopsy evaluation alone. Technical problems with biliary reconstruction, long cold ischemic times, non-heart beating donors, ABO blood group incompatibility, antibody-mediated rejection, and small-for-size syndrome in reduced-size or living donor livers can also cause similar manifestations in a peripheral core biopsy. 2. Some difficulties in distinguishing between sclerosing cholangitis and chronic rejection (CR) arise because: a) at risk populations are similar; b) both can cause "cholestatic" elevation of liver injury tests; and c) both can lead to intrahepatic cholestasis and small bile duct loss. 3. Etiopathogenesis and pathology of CR and sclerosing cholangitis have some overlapping features, but show distinct differences that result in significantly different and discriminating pathologic manifestations. 4. Clues in the clinical history, evaluation of serial biopsies, and histopathology can be used to distinguish with confidence between sclerosing cholangitis and CR. 5. Potential discriminating features include liver size and gross appearance, and histopathology findings in the arterial tree, hilar lymph nodes, large and small bile ducts, interface zone, lobular, and perivenular regions.

A difficult case of primary sclerosing cholangitis

1. The immediate postoperative concerns in a patient with primary sclerosing cholangitis. 2. Recognize the difficulties in assessing biliary health in patients that have had complicated postoperative biliary concerns. 3. Recognize the difficulty in ascertaining the presence of chronic rejection vs. recurrent primary sclerosing cholangitis.

Diagnostic benefit of biliary brush cytology in cholangiocarcinoma in primary sclerosing cholangitis

BACKGROUND/AIMS

Primary sclerosing cholangitis (PSC) is associated with a high risk of cholangiocarcinoma development. Efforts should be made to detect early neoplastic changes that can be radically treated by liver transplantation.

METHODS

In this prospective case series we obtained brush cytology specimens from bile duct strictures in 61 consecutive PSC patients. The cytological classifications were compared with histopathological findings in bile ducts from explanted livers or clinical outcome.

RESULTS

Among patients with cytological low-grade (n=9; 15%) or high-grade dysplasia/adenocarcinoma (n=13; 21%), 8 (36%) proved to have cholangiocarcinoma and 7 (32%) to have high-grade dysplasia (i.e. cholangiocarcinoma in situ) in bile ducts from explanted livers. The sensitivity, specificity, positive- and negative predictive values, and accuracy of brush cytology in diagnosis of biliary malignancy were 100%, 84%, 68%, 100%, and 88% for the combination of low-grade and high-grade dysplasia/adenocarcinoma and 73%, 95%, 85%, 91%, and 90% for high-grade dysplasia/adenocarcinoma only. All patients with high-grade biliary epithelial dysplasia in explanted bile ducts were tumour free at follow-up.

CONCLUSIONS

Brush cytology from bile duct strictures in PSC patients can detect cholangiocarcinoma in situ. Patients with cytological low-grade and high-grade dysplasia/adenocarcinoma are currently referred for liver transplantation in our hospital.